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  • Laser = light amplification by stimulated emission of radiation
  • Focalized high energy → instant coagulation → reduced bleeding, sparing of healthy tissues

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Type of Lasers
Type of laserWavelength (nm)FeaturesType of surgery
CO210,600High vaporization superficially, little damage to deep tissuesOropharyngeal surgery, vocal cord surgery
Nd:YAG1,064Further spread, greater coagulation versus vaporizationTumor debulking, tracheal procedures
Ruby694Absorbed primarily by dark pigmentsRetinal surgery
Argon515Transmitted by water, absorbed by hemoglobinVascular lesions
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Vocal cord surgery:

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  • Complete NMB of vocal cords
  • Inhibition of pharyngeal reflexes
  • Decrease secretions (glycopyrrolate 0.2–0.4 mg IV)
  • If intubation, prefer special laser ETT (metal-coated, double cuff, small diameter); inflate cuff(s) with colored saline
  • If no intubation, typically transglottic jet ventilation

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Tissue injury:

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  • Iatrogenic injury to patient can be caused by laser:
    • Pneumothorax, blood vessel puncture, hollow viscus (trachea) rupture
    • Dental injury
  • Eye injury is of special concern, to both patient and health care provider:
    • Window to OR door should be covered
    • Everyone in OR (including patient) should wear appropriate wraparound goggles (Table below on Appropriate Eye Protection)
    • Place wet eye pads on taped patient’s eyes and under goggles

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Appropriate Eye Protection
Type of laserStructures damagedPrecautions
CO2CorneaClear lenses
Nd:YAGRetinaGreen goggles
RubyRetinaRed goggles
ArgonRetinaAmber goggles
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Venous gas embolus:

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  • Gas is often used to cool laser probe tip
  • Gas embolus can occur (especially during laparoscopic uterine surgery):
    • Saline insufflation can be used, but fluid overload is possible
  • Watch end-tidal CO2 closely. If embolus suspected, cease use of laser, support hemodynamics until embolus resolves

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Laser plume:

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  • Vaporized tissue can be inhaled by operating room personnel
  • In theory, possible vector of infection (viruses) or malignant cells
  • Consider use of high-efficiency filtration masks

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Airway fire (ETT ignition):

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  • Prevention of airway fire:
    • Limit FiO2 to lowest amount compatible with adequate patient oxygenation (21–40%)
    • Avoid N2O (supports combustion)
    • Use specially designed tube (if unavailable, wrap tube in metal foil)
    • Encourage placement of moistened pledgets around cuff by surgeons
    • Fill cuff with methylene blue–colored saline to provide surgeons with visible warning of cuff puncture
  • Treatment of airway fire:
    • Cease use of laser immediately
    • Immediately disconnect tube from circuit. This should extinguish fire quickly:
      • Extubate as soon as the fire is extinguished. If fire still persists after circuit disconnection, pour saline in mouth
    • Place tube in water after extubation
    • Reintubate patient:
      • Airway damage may increase difficulty of intubation. Consider use of difficult airway equipment. Have surgeons prepare for tracheostomy if necessary
    • Assess lung damage with bronchoscopy. Keep patient intubated postoperatively. Monitor arterial blood gases, chest radiograph; assess airway for swelling (consider steroid course)
    • ...

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